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Academic Emergency Medicine : Official... Nov 2016Traditionally, emergency department (ED) physicians rely on their clinical examination to differentiate between cellulitis and abscess when evaluating skin and soft... (Review)
Review
BACKGROUND
Traditionally, emergency department (ED) physicians rely on their clinical examination to differentiate between cellulitis and abscess when evaluating skin and soft tissue infections (SSTI). Management of an abscess requires incision and drainage, whereas cellulitis generally requires a course of antibiotics. Misdiagnosis often results in unnecessary invasive procedures, sedations (for incision and drainage in pediatric patients), or a return ED visit for failed antibiotic therapy.
OBJECTIVE
The objective was to describe the operating characteristics of point-of-care ultrasound (POCUS) compared to clinical examination in identifying abscesses in ED patients with SSTI.
METHODS
We systematically searched Medline, Web of Science, EMBASE, CINAHL, and Cochrane Library databases from inception until May 2015. Trials comparing POCUS with clinical examination to identify abscesses when evaluating SSTI in the ED were included. Trials that included intraoral abscesses or abscess drainage in the operating room were excluded. The presence of an abscess was defined by drainage of pus. The absence of an abscess was defined as no pus drainage upon incision and drainage or resolution of SSTI without pus drainage at follow-up. Quality of trials was assessed using the QUADAS-2 tool. Operating characteristics were reported as sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-), with their respective 95% confidence intervals (CI). Summary measures were calculated by generating a hierarchical summary receiver operating characteristic (HSROC) model.
RESULTS
Of 3,203 references identified, six observational studies (four pediatric trials and two adult trials) with a total of 800 patients were included. Two trials compared clinical examination with clinical examination plus POCUS. The other four trials directly compared clinical examination to POCUS. The POCUS HSROC revealed a sensitivity of 97% (95% CI = 94% to 98%), specificity of 83% (95% CI = 75% to 88%), LR+ of 5.5 (95% CI = 3.7 to 8.2), and LR- of 0.04 (95% CI = 0.02 to 0.08).
CONCLUSION
Existing evidence indicates that POCUS is useful in identifying abscess in ED patients with SSTI. In cases where physical examination is equivocal, POCUS can assist physicians to distinguish abscess from cellulitis.
Topics: Abscess; Adult; Anti-Bacterial Agents; Cellulitis; Female; Humans; Male; Observational Studies as Topic; Physical Examination; Point-of-Care Systems; Sensitivity and Specificity; Soft Tissue Infections; Ultrasonography
PubMed: 27770490
DOI: 10.1111/acem.13049 -
International Journal of... 2023Spinal epidural abscess (SEA) is a rarest form of spinal infections and is characterized by the presence of pus in the space between the dura mater, and the...
Spinal epidural abscess (SEA) is a rarest form of spinal infections and is characterized by the presence of pus in the space between the dura mater, and the osseoligamentous confines of the vertebral canal. This can cause spinal injury due to direct compression or local ischemia. The major etiology of SEA is bacterial and tuberculous in endemic regions. The incidence of fungal spinal abscess is relatively low and <5% of SEA is attributable to fungi. We, here, report a case of 77-year-old known patient of chronic renal disease on hemodialysis that presented with low-back pain for 15 days and was subsequently diagnosed with SEA by magnetic resonance imaging, and causative organism was identified as Candida by culture. The abscess was surgically drained after laminectomy. The patient improved with surgery and antifungal treatment.
Topics: Humans; Aged; Spine; Epidural Abscess; Laminectomy; Magnetic Resonance Imaging
PubMed: 37721246
DOI: 10.4103/ijmy.ijmy_115_23 -
Langenbeck's Archives of Surgery Sep 2022Pyogenic liver abscess (PLA) is a collection of pus in the liver, often without a known direct cause. There is discord on the best diagnostic and therapeutic strategy....
PURPOSE
Pyogenic liver abscess (PLA) is a collection of pus in the liver, often without a known direct cause. There is discord on the best diagnostic and therapeutic strategy. We aimed to examine these questions in our patient cohort.
METHODS
A total of 66 out of 309 patients with PLA at our tertiary referral center between 2012 and 2020 had a primarily unknown cause. We analyzed PLA configuration, comorbidities, and whether an underlying cause could be found later. Therapy was sorted by antibiotics alone, percutaneous drainage, and primary surgery. Success was assessed by a change of initial therapy, in-hospital mortality, and mean hospital stay.
RESULTS
Overall mortality was 18%; in 55%, a causative condition could be found. CRP, GGT, size, and multiple localization go along with higher mortality. Antibiotics alone had a failure rate of 82%. Percutaneous drainage was successful in 70% of cases. Surgery was mainly reserved for failed previous non-surgical treatment and had in-hospital mortality of 12%.
CONCLUSIONS
PLA goes along with high mortality. In the majority of all patients, a causative condition can be identified by detailed diagnostics. Percutaneous drainage together with antibiotics is the therapy of choice and is successful in 70% of cases. If drainage is insufficient or impossible, surgery is an effective alternative.
Topics: Anti-Bacterial Agents; Drainage; Humans; Liver Abscess, Pyogenic; Retrospective Studies
PubMed: 35635587
DOI: 10.1007/s00423-022-02535-3 -
BMJ Open Apr 2023To determine whether early ear and upper respiratory signs are associated with the development of high levels of autistic traits or diagnosed autism. (Observational Study)
Observational Study
Associations between autistic traits and early ear and upper respiratory signs: a prospective observational study of the Avon Longitudinal Study of Parents and Children (ALSPAC) geographically defined childhood population.
OBJECTIVE
To determine whether early ear and upper respiratory signs are associated with the development of high levels of autistic traits or diagnosed autism.
DESIGN
Longitudinal birth cohort: Avon Longitudinal Study of Parents and Children (ALSPAC).
SETTING
Area centred on the city of Bristol in Southwest England. Eligible pregnant women resident in the area with expected date of delivery between April 1991 and December 1992 inclusive.
PARTICIPANTS
10 000+ young children followed throughout their first 4 years. Their mothers completed three questionnaires between 18-42 months recording the frequency of nine different signs and symptoms relating to the upper respiratory system, as well as ear and hearing problems.
OUTCOME MEASURES
Primary-high levels of autism traits (social communication, coherent speech, sociability, and repetitive behaviour); secondary-diagnosed autism.
RESULTS
Early evidence of mouth breathing, snoring, pulling/poking ears, ears going red, hearing worse during a cold, and rarely listening were associated with high scores on each autism trait and with a diagnosis of autism. There was also evidence of associations of pus or sticky mucus discharge from ears, especially with autism and with poor coherent speech. Adjustment for 10 environmental characteristics made little difference to the results, and substantially more adjusted associations were at p<0.001 than expected by chance (41 observed; 0.01 expected). For example, for discharge of pus or sticky mucus from ears the adjusted odds ratio (aOR) for autism at 30 months was 3.29 (95% CI 1.85 to 5.86, p<0.001), and for impaired hearing during a cold the aOR was 2.18 (95% CI 1.43 to 3.31, p<0.001).
CONCLUSIONS
Very young children exhibiting common ear and upper respiratory signs appear to have an increased risk of a subsequent diagnosis of autism or demonstrated high levels of autism traits. Results suggest the need for identification and management of ear, nose and throat conditions in autistic children and may provide possible indicators of causal mechanisms.
Topics: Humans; Child; Female; Pregnancy; Child, Preschool; Longitudinal Studies; Autistic Disorder; Prospective Studies; Parents; Suppuration
PubMed: 37094879
DOI: 10.1136/bmjopen-2022-067682 -
International Wound Journal Aug 2023This study evaluates the effect of nursing staff's renewed consistent pressure ulcer (PU) prevention practice on PU prevalence and the PU prevention implemented for... (Randomized Controlled Trial)
Randomized Controlled Trial
This study evaluates the effect of nursing staff's renewed consistent pressure ulcer (PU) prevention practice on PU prevalence and the PU prevention implemented for residents. A quasi-experimental intervention study was conducted. The data were collected from 232 residents (n = 115 in intervention and 117 in comparison group) in two public long-term older people care (LOPC) facilities in Finland using the Pressure Ulcer Patient instrument (PUP-Instrument). The facilities were chosen with convenience sampling, after which they were randomly allocated as either intervention or comparison facility. Based on international guidelines for PU prevention, the renewed, consistent PU prevention practice with six areas was developed and implemented using the operational model for evidence-based practices (OMEBP). After the intervention, a significant difference between the intervention and the comparison facility was seen in the prevalence of PUs and in the residents' highest stage of PUs in the sacrum, buttock and hip areas, and heels. Between the facilities, a significant difference was seen in the use of PU and nutrition risk assessment instruments and nutritional supplements, time used for repositioning in the daytime and at night-time, lifting belt use, and avoiding shearing or stretching residents' skin. The successful intervention improved skin integrity in LOPC facilities.
Topics: Aged; Humans; Long-Term Care; Pressure Ulcer; Prevalence; Skin Care; Suppuration
PubMed: 36584884
DOI: 10.1111/iwj.14067 -
Alzheimer's Research & Therapy Mar 2023Alzheimer's disease (AD) is a major global health crisis in need of more effective therapies. However, difficult choices to optimize value-based care will need to be...
BACKGROUND
Alzheimer's disease (AD) is a major global health crisis in need of more effective therapies. However, difficult choices to optimize value-based care will need to be made. While identifying preferred therapeutic attributes of new AD therapies is necessary, few studies have explored how preferences may vary between the stakeholders. In this study, the trade-offs among key attributes of amyloid plaque-lowering therapies for AD were assessed using a discrete choice experiment (DCE) and compared between caregivers and neurologists.
METHODS
An initial pilot study was conducted to identify the potentially relevant features of a new therapy. The DCE evaluated seven drug attributes: clinical effects in terms of delay in AD progression over the standard of care (SOC), variation in clinical effects, biomarker response (achieving amyloid plaque clearance on PET scan), amyloid-related imaging abnormalities-edema (ARIA-E), duration of therapy, need for treatment titration as well as route, and frequency of drug administration. Respondents were then randomly presented with 12 choice sets of treatment options and asked to select their preferred option in each choice set. Hierarchical Bayesian regression modeling was used to estimate weighted preference attributes, which were presented as mean partial utility scores (pUS), with higher scores suggesting an increased preference.
RESULTS
Both caregivers (n = 137) and neurologists (n = 161) considered clinical effects (mean pUS = 0.47 and 0.82) and a 5% incremental in ARIA-E (mean pUS = - 0.26 and - 0.52) to be highly impactful determinants of therapeutic choice. In contrast, variation in clinical effects (mean pUS = 0.12 and 0.14) and treatment duration (mean pUS = - 0.02 and - 0.13) were the least important characteristics of any new treatment. Neurologists' also indicated that subcutaneous drug delivery (mean pUS = 0.42 vs. 0.07) and administration every 4 weeks (mean pUS = 1.0 vs. 0.20) are highly desirable therapeutic features. Respondents were willing to accept up to a 9% increment in ARIA-E for one additional year of delayed progression.
CONCLUSIONS
Caregivers and neurologists considered incremental clinical benefit over SOC and safety to be highly desirable qualities for a new drug that could clear amyloid plaques and delay clinical progression and indicated a willingness to accept incremental ARIA-E to achieve additional clinical benefits.
Topics: Humans; Alzheimer Disease; Choice Behavior; Caregivers; Plaque, Amyloid; Neurologists; Pilot Projects; Bayes Theorem; Suppuration
PubMed: 36964606
DOI: 10.1186/s13195-023-01207-8 -
Liver International : Official Journal... Apr 2021Pyogenic liver abscesses (PLA) are space-occupying lesions in the liver that produce high morbidity and mortality. The clinical characteristics and prognosis of...
BACKGROUND & AIMS
Pyogenic liver abscesses (PLA) are space-occupying lesions in the liver that produce high morbidity and mortality. The clinical characteristics and prognosis of abscesses is different depending on the bacterial culture results and require different strategies for management. The aim of this study was to investigate the clinical characteristics and prognostic factors of patients with PLA.
METHODS
Clinical features, laboratory tests and etiology of PLA between 2006 to 2011 and 2012 to 2017 in a single hospital were retrospectively reviewed. The incidence and mortality of PLA caused by Escherichia coli and Klebsiella pneumoniae were compared and the risk factors for multiple organ dysfunction (MODS) and endophthalmitis were evaluated.
RESULTS
Among the 1,572 PLA patients, the proportion with PLA increased from 333 (21.2%) in 2006-2011 to 1,239 (78.8%) in 2012-2017 without any investigation and treatment procedure differences. K pneumoniae was the main isolate in analysed pus cultures (85.6%). The mortality rate of patients with K pneumoniae infection was lower in the latter period (6.7% vs 0.7%, P = .035). Multivariate analyses revealed that age, fever, MODS and length of hospital stay were factors affecting poor prognosis (death + unhealed/uncured) in PLA patients after treatment and that cardiovascular disease, pleural effusion and pulmonary infection were risk factors for MODS, while diabetes mellitus was the only risk factor for endophthalmitis. Most patients (95.5%) with PLA recovered after abscess drainage/puncture and antibiotic therapy.
CONCLUSIONS
Pleural effusion, fever, MODS and length of hospital stays were factors useful in predicting PLA outcomes.
Topics: Anti-Bacterial Agents; Escherichia coli; Humans; Klebsiella pneumoniae; Liver Abscess, Pyogenic; Retrospective Studies; Risk Factors
PubMed: 33314531
DOI: 10.1111/liv.14760 -
International Wound Journal Feb 2023The present study sought to explore the impact of movement monitoring devices on risk prediction and prevention of pressure ulcers (PU) among adults. Using systematic... (Review)
Review
The present study sought to explore the impact of movement monitoring devices on risk prediction and prevention of pressure ulcers (PU) among adults. Using systematic review methodology, we included original research studies using a prospective design, written in English, assessing adult patients' movement in bed, using a movement monitoring device. The search was conducted in March 2021, using PubMed, CINAHL, Scopus, Cochrane, and EMBASE databases, and returned 1537 records, of which 25 met the inclusion criteria. Data were extracted using a pre-designed extraction tool and quality appraisal was undertaken using the evidence-based librarianship (EBL). In total, 19 different movement monitoring devices were used in the studies, using a range of physical sensing principles. The studies focused on quantifying the number and types of movements. In four studies the authors compared the monitoring system with PU risk assessment tools, with a variety of high and low correlations observed. Four studies compared the relationship between movement magnitude and frequency and the development of PUs, with variability in results also identified. Two of these studies showed, as expected, that those who made less movements developed more PU; however, the two studies also unexpectedly found that PUs occurred in both low movers and high movers. In the final two studies, the authors focused on the concordance with recommended repositioning based on the results of the monitoring device. Overall, concordance with repositioning increased with the use of a monitoring device. The synthesis of the literature surrounding bed monitoring technologies for PU risk prediction showed that a range of physical sensors can be used to detect the frequency of movement. Clinical studies showed some correlation between parameters of movement and PU risk/incidence, although the heterogeneity of approaches limits generalisable recommendations.
Topics: Humans; Adult; Pressure Ulcer; Movement; Monitoring, Physiologic; Suppuration
PubMed: 35906857
DOI: 10.1111/iwj.13902 -
European Spine Journal : Official... Sep 2007Pyogenic vertebral osteomyelitis responds well to conservative treatment at early stage, but more complicated and advanced conditions, including mechanical spinal... (Review)
Review
Pyogenic vertebral osteomyelitis responds well to conservative treatment at early stage, but more complicated and advanced conditions, including mechanical spinal instability, epidural abscess formation, neurologic deficits, and refractoriness to antibiotic therapy, usually require surgical intervention. The subject of using metallic implants in the setting of infection remains controversial, although more and more surgeons acknowledge that instrumentation can help the body to combat the infection rather than to interfere with it. The combination of radical debridement and instrumentation has lots of merits such as, restoration and maintenance of the sagittal alignment of the spine, stabilization of the spinal column and reduction of bed rest period. This issue must be viewed in the context of the overall and detailed health conditions of the subjecting patient. We think the culprit for the recurrence of infection is not the implants itself, but is the compromised general health condition of the patients. In this review, we focus on surgical treatment of pyogenic vertebral osteomyelitis with special attention to the role of spinal instrumentation in the presence of pyogenic infection.
Topics: Anti-Bacterial Agents; Combined Modality Therapy; Debridement; Humans; Orthopedic Procedures; Osteomyelitis; Spinal Diseases; Suppuration
PubMed: 17106664
DOI: 10.1007/s00586-006-0251-4 -
International Wound Journal Oct 2023In acute care facilities, the detection of pressure ulcers (PUs) relies on visual and manual examination of the patient's skin, which has been reported to be...
In acute care facilities, the detection of pressure ulcers (PUs) relies on visual and manual examination of the patient's skin, which has been reported to be inconsistent and may lead to misdiagnosis. In skin and wound research, various biophysical parameters have been extensively employed to monitor changes in skin health. Nonetheless, the transition of these measures into care settings as part of a routine clinical assessment has been limited. This study was designed to examine the spatial and temporal changes in skin biophysical parameters over the site of a category I PU, in a cohort of hospitalised patients. Thirty patients, each presenting with a category I PU, were enrolled in the study. Skin integrity was assessed at the PU-compromised site and two adjacent areas (5 and 10 cm away). Data was collected over three sessions to examine both temporal differences and longitudinal changes. Skin integrity was assessed using two biophysical parameters, namely, transepidermal water loss (TEWL) and stratum corneum (SC) hydration. In addition, the influence of intrinsic factors, namely, incontinence and mobility status, on the parameters was evaluated. TEWL values at the sites compromised by PU were statistically significantly greater (P < .001) than corresponding values at the adjacent control sites at 5 and 10 cm, which were consistent with a normative range (<20 g/h/m ). By contrast, SC hydration values did not reveal clear distinctions between the three sites, with high inter-patient variation detected at the sites. Nevertheless, individual profiles were consistent across the three sessions, and the PU site was observed to be either abnormally dry or overhydrated in different individuals. No consistent temporal trend in either parameter was evident. However, intrinsic factors were shown to influence the parameters, with females, bedridden and incontinent patients presenting significantly higher TEWL and SC hydration values (P < .05). TEWL was able to identify differences in skin responses at skin sites compromised with a category I PU when compared to healthy adjacent skin sites. Accordingly, this parameter could be included in the clinical assessment for the identification of PU risk. Further studies are required to elucidate the role of hydration and skin barrier function in the development of PUs and their ability to monitor temporal changes in skin integrity.
Topics: Female; Humans; Pressure Ulcer; Skin; Epidermis; Water; Suppuration
PubMed: 37060199
DOI: 10.1111/iwj.14194